Enrollment Request Form - 2017 Page 9
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I understand that I am joining the plan for the entire calendar year. If I want to change plans, I’ll
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need to do so between October 15 and December 7. This is the Open Enrollment Period for
Medicare Advantage and Medicare prescription drug coverage. I understand that there may be
special situations at other times during the year in which I can leave the plan.
This plan covers a specific area. If I plan to move out of the area, I will call my plan to switch to a
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plan in the new area. Medicare may not cover me when I’m out of the country. However, I have
some limited coverage near the U.S. border. I understand that if I leave this plan and don’t have
or get other Medicare prescription drug coverage or creditable prescription drug coverage (as
good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for
Medicare prescription drug coverage in the future.
I will get a Welcome Guide with an Evidence of Coverage (EOC). (The EOC is also known as a
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member contract or subscriber agreement.) The EOC will list services the plan covers, as well as
the plan’s terms and conditions. The plan will cover services it approves, as well as services
listed in the EOC. If a service isn’t listed in the EOC or approved by the plan, Medicare and the
plan won’t pay for it. If I disagree with how the plan covers my care, I have the right to make an
appeal.
I understand I must use network pharmacies except in an emergency. I have the right to make an
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appeal if I disagree with how the plan covers or pays for services.
My plan will give my information, including my prescription drug event data, to Medicare and
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other plans when needed for treatment, payment and health care operations. Medicare uses the
information to understand how my care was handled or billed. Other plans may need my
information when they help pay for my care. Medicare may also give my information for research
and other purposes. All federal laws and rules protecting my privacy will be followed.
I understand that my state may offer help and advice with Medicare supplement insurance or
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other Medicare Advantage or Prescription Drug Plan options, medical assistance through the
state Medicaid program, and the Medicare Savings Program.
If I get help from a sales agent, broker or someone who has a contract with the plan, the plan
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may pay that person for this help.
The information on this form is correct, to the best of my knowledge. I understand that if I put
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information on this form that I know is not true, I will lose the plan.
When I sign below, it means that I have read and understand the information on this form.
If I sign as an authorized representative, it means that I have the legal right under state law to sign.
I can show written proof of this right if Medicare asks for it.
Signature of Applicant / Member / Authorized Representative:
MM
/
DD
/
YYYY
Today’s Date:
Enrollee Name
PDEX17PD3877053_000
Y0066_160609_110859 Approved
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